Expense incurred plans — These plans are closely associated with the term “mini med” and are a derivative of major medical (traditional) insurance. These so called “mini meds” have been popular with employers and low-wage workers for many years, because they have extremely low premiums and are generally offered on a low weekly payroll deduction basis, making them seem very affordable.

These low premiums are actually a result of highly restrictive monthly or annual limits or “caps” on benefits. These “caps,” along with other financial “barriers” such as: pre-existing condition limits, copayments/co-insurance and deductibles further reduce insurance company exposure. An unanticipated (although many think it is by design) consequence of a “low cap” mini med, is the unfortunate tendency for it to be confused with comprehensive major medical coverage, this has proven to be a very real problem for all parties concerned.

Since these plans are marketed to low-income, high-turnover groups and often contain a preexisting condition elimination period, enrollees often have left their jobs before they’re even eligible for benefits. Even when claims are incurred and filed properly they are, more often than not, rejected or delayed as a pre-existing condition (adverse selection due to chronic conditions is far more common with high-turnover, low-income employee groups)

To many of us, the good news coming out of PPACA is that, as of Nov. 23, most of these (expense incurred mini med plans) will be tightly regulated under the “cap limit” rules. In our view, we will begin to see these plans exit the industry beginning this year.

Fixed indemnity plans (the ones you don’t hear much about) — Also known as supplemental/hospital indemnity or defined benefit plans, they serve the same general purpose and also provide affordable benefits to the employer market, as the mini med plans described above.

Indemnity limited medical plans are filed, approved and thereby regulated differently than expense incurred (mini med) plans and are not subject to most of the “cap limits” imposed on mini med plans. This very significant difference allows indemnity limited med plans to continue to be freely marketed to new employers and in many cases to take over (rescue) existing expense incurred mini med business. (Note: indemnity plans are not easily confused with traditional insurance because they do not use traditional insurance terminology, such as deductibles, co-insurance, reasonable and customary and coordination of benefits)

Differentiating features of fixed indemnity plans versus expense incurred mini meds:

• First dollar benefits
• Terminology – no use of traditional insurance terms (deductible, co-insurance, copayments)
• No pre-existing condition limitations on outpatient services
• Easier to explain and understand (fixed dollar benefits for covered services)
• Claims can be more easily adjudicated (no pre-ex)
• Similar premium amounts compared to mini meds
• Generally higher payouts for hospital surgical claims
• Not subjected to federal law restricting annual or lifetime caps
• Direct assignment of claims to providers (not reimbursement to member)

A side note: Often these plans are confused with so-called “worksite benefits” — payroll-deducted, specified illness plans such as ones offered by some of the larger carriers. Limited medical plans differentiate themselves from voluntary worksite products in three ways; They are guaranteed issue, have one rate (not age banded for rates purposes) and are more likely paid for by employers. Limited medical and worksite plans operate side by side, but are not the same thing. Fixed indemnity limited medical plans offer a viable alternative (or improvement) to group expense incurred mini meds.

These plans are clearly less restrictive and confusing. The indemnity model has the additional advantage of being flexible enough to be offered as a supplement (first dollar foundation) for high-deductible major medical plans. Hopefully, this information will prove useful as new (to many) or clarifying information (to others) to counter myths and the confusion brought about by recent political and media portrayal of the products under the heading “Mini Med.”